Anterior Cervical Discectomy and Fusion With a No-Profile Integrated Fixation Allograft Device: An In Vitro Biomechanical Analysis and Clinical Case Series.

BACKGROUND: No-profile anterior cervical discectomy and fusion (ACDF) devices are commonplace in spinal surgery. Contained within the intervertebral margins, these devices diminish risks associated with anterior cervical plating, while also marginalizing cage migration and subsidence. However, these devices have been limited in their scope of implant material. Accordingly, a no-profile ACDF (npACDF) device supporting a machined allograft implant body with a connected load-sharing fixation interface was developed. However, it is not established in the literature whether the device supports early mechanical stability and subsequent boney fusion. The objective of this study was to assess this device in both the clinical and preclinical settings. METHODS: Biomechanical Analysis: Twenty-four functional spinal units (FSUs) were divided into 4 groups (n = 6). Each group would receive a single construct: (1) npACDF device with connected polyetheretherketone (PEEK) body, (2) npACDF with connected allograft body, (3) npACDF (allograft body) with nonconnected fixation plate, and (4) standard ACDF plate and PEEK interbody cage. FSUs were subjected to pure moment loading (flexion/extension, lateral bending, and axial rotation) via a kinematic test machine in their intact state and then following instrumentation. Vertebral motion was recorded and range-of-motion (ROM) reduction, relative to intact, was calculated.Clinical Case Series: Ten patients receiving single-level ACDF with the npACDF allograft (connected) device for the treatment of persistent cervical radiculopathy or myelopathy were retrospectively reviewed at 12 months. Radiographic and patient reported outcomes were reported. RESULTS: No differences in ROM existed between the npACDF constructs (P ≥ 0.99). Standard ACDF achieved more ROM reduction than the npACDF constructs in all directions (P ≥ 0.04). All subjects achieved fusion at 12 months. CONCLUSIONS: The npACDF allograft device supported less motion reduction in comparison to traditional plating; however, case series data suggest the device provides clinically effective stability resulting in quality radiographic fusion and pain improvement. CLINICAL RELEVANCE: This report provides both clinical and preclinical insight into a device which offers alternative design features to traditional continuous/rigid ACDF device designs.

Differential Agnostic Effect Size Analysis of Lumbar Stenosis Surgeries.

STUDY DESIGN: A meta-analysis of 89 randomized prospective, prospective, and retrospective studies on spinal endoscopic surgery outcomes. OBJECTIVE: The study aimed to provide familiar Oswestry Disability Index (ODI), visual analog scale (VAS) back, and VAS leg effect size (ES) data following endoscopic decompression for sciatica-type back and leg pain due to lumbar herniated disc, foraminal, or lateral recess spinal stenosis. BACKGROUND: Higher-grade objective clinical outcome ES data are more suitable than lower-grade clinical evidence, including cross-sectional retrospective study outcomes or expert opinion to underpin the ongoing debate on whether or not to replace some of the traditional open and with other forms of minimally invasive spinal decompression surgeries such as the endoscopic technique. METHODS: A systematic search of PubMed, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials from 1 January 2000 to 31 December 2019 identified 89 eligible studies on lumbar endoscopic decompression surgery enrolling 23,290 patient samples using the ODI and VAS for back and leg pain used for the ES calculation. RESULTS: There was an overall mean overall reduction of ODI of 46.25 (SD 6.10), VAS back decrease of 3.29 (SD 0.65), and VAS leg reduction of 5.77 (SD 0.66), respectively. Reference tables of familiar ODI, VAS back, and VAS leg show no significant impact of study design, follow-up, or patients' age on ES observed with these outcome instruments. There was no correlation of ES with long-term follow-up (P = 0.091). Spinal endoscopy produced an overall ODI ES of 0.92 extrapolated from 81 studies totaling 12,710 patient samples. Provided study comparisons to tubular retractor microdiscectomy and open laminectomy showed an ODI ES of 0.9 (2895 patients pooled from 16 studies) and 0.93 (1188 patients pooled from 5 studies). The corresponding VAS leg ES were 0.92 (12,631 endoscopy patients pooled from 81 studies), 0.92 (2348 microdiscectomy patients pooled from 15 studies), and 0.89 (1188 open laminectomy patients pooled from 5 studies). CONCLUSION: Successful clinical outcomes can be achieved with various lumbar surgeries. ESs with endoscopic spinal surgery are on par with those found with open laminectomy and microsurgical decompression. CLINICAL RELEVANCE: This article is a meta-analysis on the benefit overlap between lumbar endoscopy, microsurgical decompression, laminectomy, and lumbar decompression fusion.

Prosthetic design of reverse shoulder arthroplasty contributes to scapular notching and instability.

AIM: To evaluate whether implant design, glenoid positioning, and other factors influenced instability and scapular notching in reverse total shoulder arthroplasty. METHODS: We retrospectively reviewed records of patients who had undergone reverse total shoulder arthroplasty by the senior author from July 2004 through October 2011 and who had at least 24 mo of follow-up. The 58 patients who met the criteria had 65 arthroplasties: 18 with a Grammont-type prosthesis (Grammont group) and 47 with a lateral-based prosthesis (lateral-design group). We compared the groups by rates of scapular notching and instability and by radiographic markers of glenoid position and tilt. We also compared glenoid sphere sizes and the number of subscapularis tendon repairs between the groups. Rates were compared using the Fisher exact test. Notching severity distribution was compared using the χ2 test of association. Significance was set at P < 0.05. RESULTS: The Grammont group had a higher incidence of scapular notching (13 of 18; 72%) than the lateral-design group (11 of 47; 23%) (P < 0.001) and a higher incidence of instability (3 of 18; 17%) than the lateral-design group (0 of 47; 0%) (P = 0.019). Glenoid position, glenoid sphere size, and subscapularis tendon repair were not predictive of scapular notching or instability, independent of implant design. With the lateral-based prosthesis, each degree of inferior tilt of the baseplate was associated with a 7.3% reduction in the odds of developing notching (odds ratio 0.937, 95%CI: 0.894-0.983). CONCLUSION: The lateral-based prosthesis was associated with less instability and notching compared with the Grammont-type prosthesis. Prosthesis design appears to be more important than glenoid positioning.

Local versus distal transplantation of human neural stem cells following chronic spinal cord injury.

BACKGROUND CONTEXT: Previous studies have demonstrated functional recovery of rats with spinal cord contusions after transplantation of neural stem cells adjacent to the site of acute injury. PURPOSE: The purpose of the study was to determine if the local or distal injection of neural stem cells can cause functional difference in recovery after chronic spinal cord injury. STUDY DESIGN/SETTING: Twenty-four adult female Long-Evans hooded rats were randomized into four groups, with six animals in each group: two experimental and two control groups. Functional assessment was measured after injury and then weekly for 6 weeks using the Basso, Beattie, and Bresnahan locomotor rating score. Data were analyzed using two-sample t test and linear mixed-effects model analysis. METHODS: Posterior exposure and laminectomy at the T10 level was used. Moderate spinal cord contusion was induced by the Multicenter Animal Spinal Cord Injury Study Impactor with 10-g weight dropped from a height of 25 mm. Experimental subjects received either a subdural injection of human neural stem cells (hNSCs) locally at the injury site or intrathecal injection of hNSCs through a separate distal laminotomy 4 weeks after injury. Controls received control media injection either locally or distally. RESULTS: A statistically significant functional improvement in subjects that received hNSCs injected distally to the site of injury was observed when compared with the control (p=.042). The difference between subjects that received hNSCs locally and the control did not reach statistical significance (p=.085). CONCLUSIONS: The transplantation of hNSCs into the contused spinal cord of a rat led to significant functional recovery of the spinal cord when injected distally but not locally to the site of chronic spinal cord injury.

Gunshot femoral fractures with vascular injury: a retrospective analysis.

OBJECTIVE: To retrospectively investigate the experience at one urban level one trauma center with gunshot femoral fractures with vascular injury and to examine the implication of surgical sequence with regards to short-term complications and ischaemia time. METHODS: We performed a retrospective study of 24 patients treated at an urban level one trauma center over a 10-year period with low velocity gunshot wounds resulting in femur fractures and major vascular injury. Data were stratified according to sequence of surgical intervention. RESULTS: The mean age was 31.3 years. Mean time to revascularization was highest in patients undergoing definitive orthopaedic fixation first (660 min) and lowest in patient undergoing shunting first (210 min). Most complications in patients undergoing vascular repair first, included two disrupted repairs requiring immediate revision after subsequent orthopaedic fixation. Other complications included compartment syndrome and one amputation. CONCLUSION: Surgical sequence did not appear to impact the outcome with regard to limb loss, compartment syndrome, or mortality. Orthopaedic repair following vascular repair, however, is a risk for disruption of the vascular repair. We suggest that close and early direct communication between the orthopaedic and vascular surgeons take place in order to facilitate a satisfactory outcome.

Rehabilitation after anteromedialization of the tibial tuberosity.

Various surgical procedures are currently being used to treat symptomatic patellar instability. Distal bony realignment techniques attempt to correct malalignment by shifting the site of insertion of the patellar tendon. Tibial tuberosity anteromedialization, also known as the Fulkerson osteotomy, is a process in which the tuberosity is transferred anteriorly and medially. Although this surgical technique has been well described in the literature and the results are generally reported to be very good, the operation requires a prolonged recovery period and little has been written specifically regarding postoperative rehabilitation. This article discusses the rationale and technique for anteromedialization and emphasizes the important principals and goals of rehabilitation.